Officials of the Department of Health and Human Services (HHS) have planned to issue in December 2009 rules to implement major provisions of the HITECH Act within the American Recovery and Reinvestment Act (ARRA). Publication on Dec. 7 of HHS' semi-annual regulatory agenda shows the schedule is on target.
The agenda lists the dates for starting Medicare incentive programs as Oct. 1, 2010, for hospitals and Jan. 1, 2011, for physicians. Obviously we will need a definition of 'meaningful use' of Electronic Health Records (EHR). As stated on page 12 below: If this rule is not published, CMS will be unable to pay incentives for the adoption and meaningful use of EHRs.
The regulatory agenda identifies actions the department intends to take. In the agenda, the following HITECH rules remain scheduled for publication in December 2009:
RIN: 0991-AB58, an Interim Final Rule with comment period to establish an initial set of data standards, implementation specifications and criteria for certification of electronic health records;
RIN: 0991-AB59, An Interim Final Rule with comment period establishing certification programs for health information technology; and
RIN: 0938-AP78, a Proposed Rule to establish policies and procedures for the Electronic Health Record Incentive Program under Medicare and Medicaid, including definitions for the meaningful use of EHRs.
These proposed rules are subject to public comment, so a final rule will not be published by December 29. (sorry eHealth Initiative, no meaningful use for your birthday :-) But this next step in the rule-making process moves the ball significantly down field. So even though Practice Fusion points out this is really only about half time, it seems so far the ONC is meeting the aggressive timelines of HITEC.
So far the predictions for the date the rule will be released:
In this talk at the Singularity Summit 2009, Ed Boyden discusses exciting new brain-computer interfacing techniques.
How to engineer intelligent neurotechnologies to repair pathology, augment cognition, and reveal insights into the human condition (from Synthetic Neurobiology Group at MIT):
Our brains and nervous systems mediate everything we perceive, feel, decide, and do—and act as our ultimate interface to the world. An outstanding challenge for humanity is to understand these neuromedia interfaces at a level of abstraction that enables us to engineer their functions: repairing pathology, augmenting cognition, and revealing insights into the human condition. The Synthetic Neurobiology group invents and applies tools to analyze and engineer brain circuits in both humans and model systems. Our current neuroengineering focus is on devising technologies for controlling the processing within specific neural circuit targets in the brain. We hope that this synthetic neurobiology approach to the brain will help us better understand—and engineer improvements upon—the nature of human existence.
Neural stimulation hardware has traditionally been either electrical or magnetic in nature. Our lab has recently developed optogenetic molecular methods for making neurons able to be activated or silenced by multiple colors of light. We are engineering optical hardware systems for targetedly stimulating and inactivating neurons precisely, from one to many at a time, with complex spatiotemporal patterns, even in dense tissue in the living brain. Our goal is to find ways to cure intractable psychiatric and neurological disorders.
Ed Boyden MIT Media Lab & Dept. of Biological Engineering
Ed Boyden invents and applies tools for the analysis and engineering of brain circuits in humans and research animals. He is developing new strategies for systematically repairing brain pathologies, such as epilepsy, anxiety, and Parkinson’s disease, and also for augmenting cognition in diseases like Alzheimer’s. His research integrates nanotechnological, molecular, optical, and other technologies into interfaces for the precise control of neural circuit dynamics and function. He and his colleagues have created a genetically targeted way to activate and inactivate neurons using millisecond-timescale pulses of light. This innovation is now in widespread use.
Dr. Boyden is the Benesse Career Development Professor at the MIT Media Lab, in the MIT Department of Biological Engineering, and the MIT McGovern Institute. He received a Ph.D. in Neuroscience from Stanford University in 2005. He holds a double B.S. in Physics and Electrical Engineering and Computer Science and a M.Eng. in Electrical Engineering and Computer Science from MIT. In 2006 he was named one of the world’s top 35 innovators under age 35 by Technology Review magazine. In 2007, he received a Wallace H. Coulter Early Career Award, an NIH Director’s New Innovator Award, and the Society for Neuroscience Research Award for Innovation in Neuroscience, for his work on optical control of neurons.
The Centers for Medicare & Medicaid Services (CMS) has published the final rule with comment establishing the Medicare Part B physician fee schedule for CY 2010 (Rule). The fee schedule, which was published in the Federal Register on November 25, 2009, reflects a 21.2 percent cut in Medicare payments as mandated by the sustainable growth rate (SGR), adopted by Congress in 1997. As with prior years, Congress is expected to intervene to override the proposed reduction.
Medicare pays for physician services under a fee schedule methodology based on national uniform relative value units (RVUs) which are calculated on the basis of resources used in furnishing a service. The RVUs are converted to a dollar amount by application of a conversion factor.
CMS has released the corrections below to be published in the Federal Register December 10, 2009:
The DiCarlo Lab (McGovern Institute for Brain Research at MIT) and the Cox Lab (Rowland Institute at Harvard University) have built this 16-GPU 'monster' supercomputer as part of their research efforts to build artificial vision systems inspired by the human brain. The 18" x18" x18" cube may be one of the most compact and inexpensive supercomputers in the world. Photo - Photo courtesy Nicolas Pinto / MIT
Taking inspiration from genetic screening techniques, researchers from MIT and Harvard have demonstrated a way to build better artificial visual systems with the help of low-cost, high-performance gaming hardware.
The neural processing involved in visually recognizing even the simplest object in a natural environment is profound — and profoundly difficult to mimic. Neuroscientists have made broad advances in understanding the visual system, but much of the inner workings of biologically based systems remain a mystery.
Using Graphics Processing Units (GPUs) — the same technology video game designers use to render life-like graphics — MIT and Harvard researchers are now making progress faster than ever before. “We made a powerful computing system that delivers over hundred fold speed-ups relative to conventional methods,” said Nicolas Pinto, a PhD candidate in James DiCarlo’s lab at the McGovern Institute for Brain Research at MIT. “With this extra computational power, we can discover new vision models that traditional methods miss.” Pinto co-authored the PLoS study with David Cox of the Visual Neuroscience Group at the Rowland Institute at Harvard.
How they did it: Harnessing the processing power of dozens of high-performance NVIDIA graphics cards and PlayStation 3s gaming devices, the team designed a high-throughput screening process to tease out the best parameters for visual object recognition tasks. The resulting model outperformed a crop of state-of-the-art vision systems across a range of tests -- more accurately identifying a range of object s on random natural backgrounds with variation in position, scale, and rotation. Had the team used conventional computational tools, the one-week screening phase would have taken over two years to complete.
Next steps: The researchers say that their high-throughput approach could be applied to other areas of computer vision, such as face identification, object tracking, pedestrian detection for automotive applications, and gesture and action recognition. Moreover, as scientists better understand what components make a good artificial vision system, they can use these hints to better understand the human brain as well.
Source: Pinto N, Doukhan D, DiCarlo JJ, Cox DD. A high-throughput screening approach to good forms of biologically-inspired visual representation. PLoS Computational Biology. Nov 26 2009. Funding: National Institutes of Health, McKnight Endowment for Neuroscience, Jerry and Marge Burnett, the McGovern Institute for Brain Research at MIT, and the Rowland Institute at Harvard. Hardware support provided by the NVIDIA Corporation.
Author(s): Karen Davis, Stuart Guterman, Sara R. Collins, Kristof Stremikis, Sheila Rustgi, and Rachel Nuzum
Editor(s): Martha Hostetter and Chris Hollander
Executive Summary
To achieve a high performance health system, health reform must go beyond ensuring affordable coverage to addressing health system changes that will improve Americans' health outcomes and the quality of health care, increase efficiency, and slow the growth in total health system costs. This report analyzes the health reform bill passed by the U.S. House of Representatives and the reform provisions under consideration in the Senate that would affect providers’ financial incentives, the organization and delivery of health care services, investment in prevention and population health, and the capacity to achieve the best health care and health outcomes for all.
Congress has fashioned health reform plans that will fundamentally change our present course of rising costs and increasing numbers of uninsured and underinsured people. The bills represent a pragmatic approach to closing the gaps in insurance coverage by: building on a mix of employer coverage, other private plans, and a public plan in a health insurance exchange, or exchanges; strengthening Medicare; and expanding Medicaid. Most of the ideas that have been advanced by policymakers and health care opinion leaders to deal with rising costs are reflected in the bills.
Key Provisions Targeting Costs and Quality
Following are the key changes that the House and Senate bills would make to help ensure long-run cost containment and improve the quality of health care.
1. Changing the Insurance Market Both the House bill and the bill under consideration in the Senate would establish a health insurance exchange, or exchanges, with a choice of plans; rules to shift insurers from competing for healthier enrollees to competing on value; and greater transparency. While the Congressional Budget Office (CBO) does not credit savings that would be generated from increased competition among plans, it estimates that the insurance exchange would lower administrative overhead by four to five percentage points. In the authors’ view, the House provisions for the insurance exchange would be effective over the long term in mitigating the rise in premiums and costs to employers and households. These provisions include: creation of an 85 percent medical-loss-ratio standard; standardized benefit tiers to facilitate comparison of plan premiums; review of plan premiums by the Secretary of Health and Human Services (HHS), who would have the authority to reject plans with excessive increases; and repeal of the health insurance companies’ exemption from antitrust regulation. These positive effects would grow if the exchange is gradually opened to larger firms (an option after the year 2015 in the House bill, and after 2017 in the Senate bill). According to a recent Commonwealth Fund survey of health care opinion leaders, support for establishment of a health insurance exchange is overwhelming (92%).
2. Offering a Public Plan The House bill would offer a public health plan in the insurance exchange. The HHS secretary would be charged with negotiating provider payment rates and authorized to use an array of proven value-based purchasing payment methods. Providers participating in Medicare would be assumed to participate in the public health insurance plan unless they opt out. CBO estimates that the public plan will have lower administrative costs than private plans but also will attract sicker individuals, with the net effect that its premium will be slightly higher than those for private plans. As a result, CBO estimates that nearly all of the 6 million people who enroll in the public plan (of the nearly 30 million covered through the exchange) would be people who are currently uninsured and who would be eligible for premium subsidies.
The Senate bill includes a community health insurance option that is publicly sponsored and negotiates provider payment rates up to the average commercial level. Individual states would be allowed to opt out of offering the option. CBO estimates that approximately one of eight people purchasing coverage through the exchange would choose a public plan. This would represent roughly 1 percent of the 282 million nonelderly people living in the United States in 2019, or about 4 million people.
There is great uncertainty over the long-term effectiveness of the public plan option. Initially, health care providers that treat the uninsured are likely to participate, even at payment rates well below commercial rates; that's because most of those newly covered would be low-income patients for whom safety-net providers now receive little or no payment.
A Commonwealth Fund study found that a health reform proposal that includes a robust public health insurance plan—with provider payment tied to Medicare and open to all employers and individuals—could save $3 trillion in total health expenditures over the period 2010–2020. The same proposal, but with an intermediate public plan having rates between commercial providers’ and Medicare’s, was estimated to save $2 trillion. A proposal with no public plan but with Medicare reforms only, meanwhile, saved an estimated $1.2 trillion. Depending on how effective the HHS secretary is in negotiating rates and lowering administrative costs, the public plan could put significant pressure on private insurers to slow the growth in premiums for employers and workers over time as the exchange is opened to larger firms. Three-fourths of surveyed health care opinion leaders support including a public health insurance option in the exchange.
3. Instituting Provider Payment Reform The House and Senate bills would establish a Medicare and Medicaid Payment Innovation Center with broad authority for the HHS secretary to test innovative payment methods for medical homes that provide patient-centered coordinated care, for accountable care organizations that assume responsibility for quality and cost across the continuum of patient care, and for bundled hospital acute and post-acute care. The Senate bill also would implement a national, voluntary shared savings program for accountable care organizations. The secretary would have broad authority to sustain and spread effective payment methods, although participation by providers in new payment methods would be voluntary.
The House bill calls for two studies to be conducted by the Institute of Medicine. The secretary would be authorized to implement the recommendations of one study, on geographic adjustment factors in Medicare payment. The secretary also would be authorized to implement the recommendations of the second study, on geographic variation in health spending and promotion of high-value health care, unless Congress votes to disapprove it. Nearly all health care opinion leaders (97%) support reforming provider payment to promote quality and efficiency.
4. Adjusting Payment for Productivity Improvement The hospital industry agreed to slow increases in Medicare payment rates in recognition of the increased revenue realized through coverage of the uninsured and the potential for significant ongoing productivity improvements. The one-percentage-point slowing in Medicare payment rates for all providers (other than physicians, whose payments are considered separately) yields $150 billion to $180 billion federal budget savings over 2010–19, according to CBO, and establishes the principle that rising expenditures cannot continue at projected rates.
5. Creating an Independent Commission The Senate bill would establish an independent commission within the executive branch that has significant authority to identify areas of waste and additional federal budget savings. The commission would first review physician and home health services; hospitals would be exempt initially. Congress would be required to make an up-or-down vote on its annual recommendations. CBO estimates the commission would generate $23 billion in savings over 2010–19, mostly in the out-years. Three-fourths of health care opinion leaders (75%) support creation of an independent advisory council that has the authority to make decisions within parameters established by Congress and subject to review by the president and Congress.
6. Negotiating Pharmaceutical Prices The House bill calls for negotiating pharmaceutical prices and for increased prescription drug rebates for beneficiaries covered by both Medicare and Medicaid. The Senate bill includes rebates, but not negotiation of pharmaceutical prices—the result of an agreement among the chairman of the Senate Finance Committee, the White House, and the pharmaceutical industry, in which the industry agreed to provide discounts of half the cost of brand-name drugs in the Medicare coverage gap, or “doughnut hole.” While CBO does not score savings from the authority to negotiate prices, the experience of other countries suggests that it could in fact yield substantial savings were it to be included in a final reform bill. Four-fifths of health care opinion leaders (81%) favor using Medicare's leverage to negotiate pharmaceutical drug prices.
7. Incentivizing Primary Care and Prevention The House and Senate bills include a number of provisions to increase primary care payment rates under Medicare and Medicaid, cover effective preventive services without patient cost-sharing, and support community and employer prevention and wellness programs. These provisions could begin to change the orientation of our health system toward primary care and away from specialty care, counter the impending shortage of primary care providers, and lay the groundwork for more fundamental payment reforms.
8. Utilizing Value-Based Benefit Design Both the House and Senate bills contain provisions that would permit patient cost-sharing and payment rates to be modified to encourage the use of services that promote health and value. The House bill allows value-based benefit design in the public health insurance plan, while insurance plans that reduce or eliminate cost-sharing for clinically beneficial care are exempt from certain requirements under the Senate proposal. These approaches could begin to reduce the use of overpriced and/or ineffective services and procedures over time. Eighty-six percent of health care opinion leaders favor granting an independent Medicare advisory council the authority to alter beneficiary incentives based on the effectiveness of services, drugs, and devices.
9. Promoting Quality Improvement and Public Reporting The Senate bill would reduce payment for hospital-acquired conditions, and both the House and Senate bills would enhance public reporting of quality and cost. Under the Senate proposal, hospitals with high rates of hospital-acquired conditions would have their Medicare reimbursement rates cut by 1 percent. The House bill would require all hospitals to publicly report their infection rates.
10. Encouraging Medicare Private Plan Competition Both the House and Senate bills would level the playing field between Medicare private plans and the traditional Medicare public health insurance plan. This would yield $140 billion to $170 billion in federal budget savings over 2010–19, according to CBO, and might encourage plans to compete on value to a greater extent, thus having at least a modest effect on health care costs. Three-fourths of health care opinion leaders (77%) support such a provision.
11. Taxing Excessive Premiums The Senate bill imposes a 40 percent excise tax on health insurance premiums over a given threshold ($8,500 for individual policies and $23,000 for family policies) beginning in 2013 (indexed to the consumer price index, plus one percentage point in subsequent years). CBO estimates this would yield revenues of $149 billion over 2010–19. The economic theory is that such a tax would reduce the number of "Cadillac" health plans—those with benefits deemed excessive. As a result, employers would cover fewer benefits and instead raise employee wages, which would generate income and payroll tax revenue. The reduced benefits and increased cost-sharing also might reduce patient utilization of services, mitigating total spending on health care.
In the authors' view, however, there is little empirical evidence that such a tax would have a substantial effect on health care spending. Unless it is carefully designed, it could penalize employees in plans with sicker, higher-risk, or older workers and firms in high-cost areas. A majority of health care opinion leaders (58%) support such a tax.
Assessing the Bills' Potential Impact
The combined effect of these provisions on trends in national health expenditures is difficult to estimate, and CBO has indicated that it does not have the modeling capacity to do so. Estimates released by the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) indicate modest increases in national health expenditures, but this estimate gives little credit for savings to measures that would reform provider payment, negotiate prescription drug prices, increase competition among plans in an insurance exchange, encourage public reporting, or apply the results of comparative effectiveness research. Yet these measures are a crucial platform for developing and implementing further policies to contain health care cost growth. As such, they have broad support from health care opinion leaders and business leaders as effective ways to control costs. A recent analysis by the Business Roundtable prepared by Hewitt, for example, found that such legislative reforms could potentially reduce the trend line in employment-based health care spending by $3,000 per employee by 2019.
CBO's estimates of federal budget impact, however, are also fraught with uncertainty, given the multitude of changes and their potentially synergistic effects. On the last three occasions when CBO has estimated the savings or costs of major health reforms (the 1982–83 Medicare changes in hospital payment, the 1997 Balanced Budget Act, and the 2003 Medicare Modernization Act covering prescription drugs), the estimates were wide of the mark—with savings more than double those estimated in the first two cases and costs overstated by 40 percent in the third.
The measures incorporated in the bills under consideration would stimulate significant changes in the organization and delivery of health services and create powerful incentives to improve efficiency and productivity. Given the uncertainties that now exist, however, it will be especially important to establish a system for monitoring progress on agreed-upon health reform goals and to provide a mechanism for mid-course corrections and further changes as needed to move the United States toward a high performance health system by 2020. Stronger measures may be required over time to move providers into value-based methods of payment. Estimates of cost and savings could be seriously underestimated or overestimated; if so, corrective actions may be required, particularly if quality or access have been compromised.
Even under current estimates, 18 million to 24 million people will remain uninsured, and many others will still face financial barriers to obtaining needed care or hardship in paying premiums or medical bills. Additional steps may be required to ensure affordability for families as well as stable financing.
Finally, the one major disappointment in the proposed health reform bills is the absence of significant incentives or levers for private insurers to control health care costs. Private insurers, in opposing a public plan, essentially have argued that they do not have the ability to slow premium growth or achieve economies, because of demands for higher prices from a powerful and increasingly consolidated health care provider sector. It is important that the HHS secretary use new discretionary authority to test multipayer provider payment reforms, and to be responsive to requests from states or local groups to test innovative approaches. Over time, as experience is gained with new provider payment methods, strategies for harmonizing public and private provider payment and leveraging their joint purchasing power will be needed to avoid having public and private provider incentives working at cross-purposes.
Congress has a historic opportunity to pass comprehensive health care reform legislation this year. Multiple strategies for improving quality and slowing the growth in total health system spending will help spark economic recovery, put the nation back on the road to fiscal responsibility, and ensure that families are able to get the care they need while having financial security and relief from rising insurance premiums.
Citation
K. Davis, S. Guterman, S. R. Collins, K. Stremikis, S.Rustgi, and R. Nuzum, Starting on the Path to a High Performance Health System: Analysis of Health System Reform Provisions of House of Representatives and Senate Health Reform Bills, The Commonwealth Fund, November 2009.
Back in August I wrote about the Gang of Six on the Finance Committee who were instrumental in getting a health reform bill to the floor of the Senate. Many of these figures are still going to be key players, but now that the full Senate is debating, some other key figures are emerging.
The crux of the matter is that those Democrats from more conservative areas, who are up for election in 2010, are leery of signing on to a bill that may cause them difficulty during this next election cycle. This most significantly includes the abortion provisions and public option plans in the bill. Add to that some other members that are from left leaning areas, who insist on including these provisions. It seems that it may be very difficult to reconcile these entrenched sides.
Here is interesting background on some of the key players to watch in the current Senate healthcare debate by USA Today:
Congressional Quarterly, Almanac of American Politics, USA TODAY research
A recent RAND Corporation study estimated the savings from electronic medical records would be about $77 billion a year. The Center for American Progress found the federal government would save $196 billion over the next ten years. Yet, from a new survey by Dr. David Himmelstein, an associate professor at Harvard Medical School, and his team, they have concluded that so far cost savings from health IT adoption have not materialized. The results of the national survey of about 4,000 hospitals were published online in the American Journal of Medicine (see study below).
Michael W. Painter, JD, MD, Senior Program Officer at the Robert Wood Johnson Foundation said:
"Research by Ashish Jha et al., in our recent EHR Adoption report (results also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system. I’m not sure how one can draw important conclusions from with such a low rate of adoption.
Mike is absolutely right! Without widespread adoption of EHR systems it is unlikely that we will ever see significant cost savings. The idea of using information technology to lower costs and increase quality has been around for a long time. Below is an excerpt from a 1966 film on the use of computers in healthcare. This segment from Akron general hospital predicts great things for computers in medicine:
The time has come to make the most of health information technology. But, it will take time before we can achieve efficiencies from better use of information technology in healthcare. John Reaves, part of the Twitter healthcare community, sent me a link to Changing Productivity Trends from the August 31, 2007 Federal Reserve Bank of San Francisco Economic Letter. There is a powerful analogy to the productivity slow down from the 1970s as workers and firms struggled to learn and implement the new information technologies; as this process moved ahead, productivity surged in the 1990s. The idea that learning is costly and may be accompanied by temporarily lower output growth makes sense.
As Dr. Blumenthal the National Coordinator for Health Information Technology said on the Health IT Buzz blog:
As a scientist myself, I take the academic literature very seriously. I believe that policy should be based on the best available information, carefully analyzed and considered. However, recent studies raising questions about the benefits of EHRs are informative, but limited in their applicability to our HIT program. To the extent that they accurately capture past experience with EHRs, these studies illustrate something that the Congress and the President understand and have allowed for: namely, that having an EHR alone is not sufficient. Doctors and hospitals have to use this technology effectively, have to employ its extraordinary power to improve clinical decisions, in order to achieve its potential benefits. The federal government’s new programs of incentives and penalties are totally focused on encouraging the meaningful use of EHRs. The resources set aside by the Congress to encourage the adoption of EHRs will go only to physicians, hospitals, and other providers who meet carefully designed new requirements for the use of EHRs that will translate into health improvements and cost reductions for the American people. And the plan passed by Congress includes new resources and support that will help make it possible for providers and hospitals to meet these requirements. We have already announced the availability of grants that will help providers adopt and use EHRs, and we will be making additional announcements in the weeks and months ahead.
The problem really comes down to "meaningful use" of health information technology. We need to ensure that implementation of health IT coincides with training, and dissemination of best practices so that the goal of reducing costs and improving quality are within reach. The conclusions drawn by the report below should give us pause... But really it just strengthens the argument that we absolutely must forge ahead on the current path. Only through wider adoption and more effective use of electronic health record systems will help to lower costs and improve clinical outcomes.
